Medicare Supplement Insurance Approved Policies List 2015

Transcription

1 Medicare Supplement Insurance Approved Policies List 2015 For more information on health insurance call: MEDIGAP HELPLINE This is a statewide toll-free number set up by the Wisconsin Board on Aging and Long Term Care and funded by the Office of the Commissioner of Insurance to answer questions about health insurance and other health care benefits for the elderly. It has no connection with any insurance company. State of Wisconsin Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI OCI's Web Site: oci.wi.gov Deaf, hearing, or speech impaired callers may reach OCI through WI TRS. PI-010 (R 03/2015)

2 The mission of the Office of the Commissioner of Insurance... Leading the way in informing and protecting the public and responding to their insurance needs. If you have a specific complaint about your insurance, refer it first to the insurance company or agent involved. If you do not receive satisfactory answers, contact the Office of the Commissioner of Insurance (OCI). To file a complaint online or to print a complaint form: OCI's Web Page oci.wi.gov Phone (608) (In Madison) or (Statewide) Mailing Address Office of the Commissioner of Insurance P.O. Box 7873 Madison, WI Electronic Mail ocicomplaints@wisconsin.gov Please indicate your name, phone number, and address. Deaf, hearing, or speech impaired callers may reach OCI through WI TRS This list contains information on Medicare supplement insurance policies approved by the Office of the Commissioner of Insurance (OCI). It includes only policies currently being sold in Wisconsin. The companies shown in this list have agreed to be listed. Group policies sold through employers are not included in this list. There are companies that currently sell Medicare supplement insurance policies approved by OCI that have chosen not to be included in the list. Premiums for the policies on the list are as of January 1, 2015, unless noted, and may change throughout the year. This list is updated on an annual basis. For more detailed information on Medicare and Medicare supplement insurance, visit our Web site or contact OCI and request a copy of the booklet, Wisconsin Guide to Health Insurance for People with Medicare. 2

3 Table of Contents Page Definitions... 5 Individual Medicare Supplement Policies Traditional Insurers... 6 Aetna Life Insurance Company... 7 American Continental Insurance Company... 9 American Republic Corp. Insurance Company American Republic Insurance Company American Retirement Life Insurance Company Blue Cross Blue Shield of Wisconsin Central States Indemnity Company of Omaha Colonial Penn Life Insurance Company Combined Insurance Company of America Family Life Insurance Company Gerber Life Insurance Company Globe Life and Accident Insurance Company Government Personnel Mutual Life Insurance Company Gundersen Health Plan, Inc Humana Insurance Company Liberty National Life Insurance Company Mutual of Omaha Insurance Company Order of United Commercial Travelers of America Pekin Life Insurance Company Physicians Mutual Insurance Company Reserve National Insurance Company Standard Life and Accident Insurance Company State Farm Mutual Automobile Insurance Company Sterling Life Insurance Company Thrivent Financial for Lutherans United American Insurance Company UnitedHealthcare Insurance Company (SecureHorizons) Western Catholic Union Wisconsin Physicians Service Insurance Corporation Group Medicare Supplement Policies Traditional Insurers UnitedHealthcare Insurance Company (AARP)

4 Medicare Supplement Policies Medicare Select Dean Health Plan, Inc Group Health Cooperative of South Central Wisconsin Health Tradition Health Plan MercyCare HMO, Inc Physicians Plus Insurance Corporation Security Health Plan of Wisconsin, Inc Unity Health Plans Insurance Corporation Medicare Cost Insurance Dean Health Plan, Inc HealthPartners Insurance Company Medica Insurance Company Medical Associates Clinic Health Plan of Wisconsin

5 Definitions Attained age: This means that as you age your premiums will change to meet your age range and your premiums will become higher. Health history: Health questions may be asked if you are enrolling at a time other than the open enrollment period. Questions may ask for limited information or may ask for detailed information about your health. Issue age: Premiums are set at the age you are when you buy the policy and will not increase because you get older. Premiums may increase for other reasons. Open enrollment period: A one-time-only six-month period when you can buy any Medicare supplement policy you want that is sold in Wisconsin. It starts when you sign up for Medicare Part B and you are age 65 or older. You cannot be denied coverage or charged more due to present or past health problems during this time period. Preexisting condition: A medical condition diagnosed or treated up to six months prior to the purchase of an insurance policy. Medicare supplement policies may impose up to a 180- day waiting period before coverage for that condition begins. Tobacco rates: If you use tobacco, an insurance company may charge you more for your insurance policy. However, this higher rate cannot be applied if you are enrolling during your open enrollment period. Waiting period: The time between the effective date of your Medicare supplement insurance policy and the date the insurance company or Medicare health plan is required to begin paying benefits for preexisting conditions. Preexisting waiting periods may not last longer than six months. 5

6 INDIVIDUAL MEDICARE SUPPLEMENT POLICIES TRADITIONAL INSURERS 6

7 Aetna Life Insurance Company 800 Crescent Centre Drive, Suite 200 Franklin, TN ( Consumer Service Telephone No Form No. GR WI 01 First-Year Commission: 17% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes , 534 Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $5, Under 65 $6, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ , , Rates effective January

8 Aetna Life Insurance Company (continued) Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Area 1: $48.00 for all ages Area 2: $42.00 for all ages Area 1: $20.00 for all ages Area 2: $17.00 for all ages Area 1: $20.00 for all ages Area 2: $17.00 for all ages Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 8

9 American Continental Insurance Company 800 Crescent Centre Drive, Suite 200 Franklin, TN ( Consumer Service Telephone No Form No. ACIMSP14BC WI First-Year Commission: 21% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $4, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ Rates effective January

10 American Continental Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Additional Home Health Visits: Foreign Travel Emergency: Area 1: $38.00 for all ages Area 2: $33.00 for all ages Area 1: $32.00 for all ages Area 2: $28.00 for all ages Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Multi-policy household discount offered. 10

11 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3103AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective January

12 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $3, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $

13 American Republic Corp. Insurance Company (continued) Area 4 Area 5 Area 6 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $24.48 $21.36 $24.48 $21.36 $24.48 $ Area 4 Area 5 Area 6 Under 65 $24.48 $21.36 $24.48 $21.36 $24.48 $ Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Age: Under 65 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. 13

14 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3120AC-WI, A3121AC-WI First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Annual Premium - Basic Policy Premiums are based on attained age. Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Rates effective January

15 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $2, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $1, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $1, $1, Under 65 $1, $1, , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $1, Under 65 $2, $1, , , , , , , , , , , , , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. 15

16 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , ,

17 American Republic Corp. Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 5 Area 5 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 4 Area 5 Area 6 Under 65 $ $ $ $ $ $

18 American Republic Corp. Insurance Company (continued) Part B Deductible ($147): Part B Excess Charges: Not Covered Not Covered Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Not Covered Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Part A Deductible (50%) offered. 18

19 American Republic Corp. Insurance Company P.O. Box Des Moines, IA ( Consumer Service Telephone No Form No. A3098AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Code 537 Area 4: Zip Codes 545, 548 Area 5: Zip Code 546 Area 6: Rest of State Annual Premium - High Deductible Plan Premiums are based on attained age. Area 1 Area 2 Age Male Female Age Male Female Under 65 $1, $1, Under 65 $1, $1, , , , , , , , , , , , Area 3 Area 4 Under 65 $1, $1, Under 65 $1, $1, , , , , , , Area 5 Area 6 Under 65 $1, $1, Under 65 $1, $1, , , , , Rates effective January

20 American Republic Corp. Insurance Company (continued) You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 20

21 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3158AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $6, $4, Under 65 $7, $5, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Rates effective January

22 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 4 Area 4 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $6, $4, , , , , , , , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $6, $4, Under 65 $7, $5, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $4, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 7 Area 7 Under 65 $5, $4, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , ,

23 American Republic Insurance Company (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 4 Area 5 Area 6 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Area 7 Age Male Female Under 65 $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Male Female Age: Under 65 $24.48 $ Additional Home Health Care: Age: Under 65 $

24 American Republic Insurance Company (continued) Foreign Travel Emergency: Age: Under 65 $ Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 24

25 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3160AC-WI, A3159AC-WI First-Year Commission: 15% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Annual Premium - Basic Policy Premiums are based on attained age. Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Rates effective January

26 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 3 Area 3 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , Area 5 Area 5 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , Area 7 Area 7 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , ,

27 American Republic Insurance Company (continued) You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , Area 4 Area 4 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , ,

28 American Republic Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - All Options Area 5 Area 5 Age Male Female Age Male Female Under 65 $4, $4, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 6 Area 6 Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 7 Area 7 Under 65 $4, $3, Under 65 $4, $3, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Annual Premium - Optional Benefits Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Not Covered Not Covered Not Covered Additional Home Health Care: Age: Under 65 $

29 American Republic Insurance Company (continued) Foreign Travel Emergency: Not Covered Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 29

30 American Republic Insurance Company P.O. Box 1 Des Moines, IA ( Consumer Service Telephone No Form No. A3161AC-WI First-Year Commission: 15% Waiting Period: None Area 1: Zip Codes 531, 532 Area 2: Zip Code 534 Area 3: Zip Codes 530, , 539, 541, 543, 549 Area 4: Zip Codes 545, 548 Area 5: Zip Code 540 Area 6: Zip Code 546 Area 7: Rest of State Annual Premium - High Deductible Plan Premiums are based on attained age. Area 1 Area 2 Age Male Female Age Male Female Under 65 $2, $2, Under 65 $2, $2, , , , , , , , , , , , , Area 3 Area 4 Under 65 $2, $2, Under 65 $2, $1, , , , , , , , , , , Area 5 Area 6 Under 65 $2, $2, Under 65 $2, $1, , , , , , , , , , , Rates effective January

31 American Republic Insurance Company (continued) Area 7 Under 65 $2, $2, , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. 31

32 American Retirement Life Insurance Company Lakeline Blvd., Suite 100 Austin, TX Consumer Service Telephone No Form No. AR-BASC-WI First-Year Commission: 13.5% - 27% Waiting Period: None Area 1: Zip Codes Area 2: Zip Codes Premiums are based on attained age. Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $3, Under 65 $5, $5, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $ $ $ $ Rates effective January

33 American Retirement Life Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female Under 65 $50.71 $44.11 $58.97 $ Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female Under 65 $ $ $ $ Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female Under 65 $37.06 $32.24 $43.09 $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Part A Deductible (50%) offered. 33

34 Blue Cross Blue Shield of Wisconsin (dba Anthem Blue Cross and Blue Shield) P.O. Box 9063 Oxnard, CA ( Consumer Service Telephone No Form No. WPPLANBASICM(09)-WI First-Year Commission: 12% Waiting Period: 6 Months Premiums are based on attained age. Area 1: Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Area 2: Brown, Dane, and Outagamie counties Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $6, Under 65 $8, $8, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $5, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $5, $5, Under 65 $7, $7, , , , , , , , , , , , , , , , , , , , , Rates effective January

35 Blue Cross Blue Shield of Wisconsin (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $1, $1, $1, $1, $1, $1, Part B Deductible ($147): Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Additional Home Health Care: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $96.24 $88.08 $81.84 $93.36 $

36 Blue Cross Blue Shield of Wisconsin (continued) Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B copayment or coinsurance rider offered. Rates for tobacco users are higher outside of open enrollment period. Different premiums for each age between age 65 and 85. Multi-policy household discount offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 36

37 Central States Indemnity Company of Omaha P.O. Box Clearwater, FL ( Consumer Service Telephone No Form No. CSBASWI Waiting Period: None First-Year Commission: Varies Premiums are based on attained age. Area 1: Zip Codes Area 2: Zip Codes , 544, 549 Area 3: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $4, $3, Under 65 $6, $5, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $3, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 3 Area 3 Under 65 $3, $2, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , Rates effective February

38 Central States Indemnity Company of Omaha (continued) Part A Deductible ($1,260): Annual Premium - Optional Benefits Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $ $ $ $ $ Part B Deductible ($147): $ for all ages, all areas Part B Excess Charges: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $ $94.00 $96.00 $85.00 $83.00 $ Additional Home Health Care: Age: Under 65 $ Foreign Travel Emergency: Area 1 Area 2 Area 3 Age Male Female Male Female Male Female Under 65 $99.00 $86.00 $89.00 $77.00 $77.00 $ Part B copayment or coinsurance rider offered. Different premiums for each age between age 65 and 85. Policy fee or administrative fee charged with initial enrollment. Part A Deductible (50%) offered. 38

39 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL-GR-A830 First-Year Commission: 16% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $6, $6, Under 65 $7, $7, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $6, $5, Under 65 $7, $6, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Area 1 Area 2 Part B Deductible ($147): $ for all ages, all areas Age Male Female Male Female Under 65 $1, $ $ $ Rates effective January

40 Colonial Penn Life Insurance Company (continued) Part B Excess Charges: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Additional Home Health Care: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Foreign Travel Emergency: Area 1 Area 2 Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Part B copayment or coinsurance rider offered. Different premiums for each age between age 65 and 85. Part A Deductible (50%) offered. Discount offered for Electronic Funds Transfer (EFT) premium payment. 40

41 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL -GR-A831, CPL-GR-A832 First-Year Commission: 16% 50% Cost-Sharing Plan 25% Cost-Sharing Plan Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - 50% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $3, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $3, $2, Under 65 $3, $2, , , , , , , , , , , , , , , , , You will pay 50% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $4,940 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Rates effective January

42 Colonial Penn Life Insurance Company (continued) Annual Premium - Basic Policy Annual Premium - 25% Cost-Sharing Plan Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $5, $4, Under 65 $5, $4, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $4, $4, Under 65 $4, $4, , , , , , , , , , , , , , , , , , , , , You will pay 25% of the cost-sharing of some covered services until you reach the calendar year out-of-pocket limit of $2,470 which will increase each year for inflation. Once you reach the annual limit, the policy pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. Part A Deductible ($1,260): Part B Deductible ($147): Part B Excess Charges: Annual Premium - Optional Benefits Not Covered Not Covered Not Covered Additional Home Health Care: Area 1 Area 2 Foreign Travel Emergency: Age Male Female Male Female All $14.84 $13.31 $13.42 $12.11 Not Covered Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. 42

43 Colonial Penn Life Insurance Company 111 East Wacker Drive, Suite 2100 Chicago, IL ( Consumer Service Telephone No Form No. CPL-GR-A834 First-Year Commission: 10% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - High Deductible Plan Area 1 Area 2 Age Male Female Age Male Female Under 65 $1, $1, Under 65 $1, $1, , , , , , , , You have to pay a calendar year deductible of $2,180. This deductible consists of expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B but does not include the separate foreign travel emergency deductible. Annual Premium - Optional Benefits Part B Excess Charges: Additional Home Health Visits: Foreign Travel Emergency: Covered at 100% after deductible Covered at 100% after deductible Covered at 100% after deductible Different premiums for each age between age 65 and 85. Discount offered for Electronic Funds Transfer (EFT) premium payment. Rates effective January

44 Combined Insurance Company of America 1000 Milwaukee Avenue Glenview, Illinois ( Consumer Service Telephone No Form No First-Year Commission: 13% Waiting Period: None Premiums are based on attained age. Area 1: Zip Codes Area 2: Rest of State Annual Premium - Basic Policy Annual Premium - All Options Area 1 Area 1 Age Male Female Age Male Female Under 65 $3, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Area 2 Area 2 Under 65 $2, $2, Under 65 $3, $3, , , , , , , , , , , , , , , , , , , , , Annual Premium - Optional Benefits Part A Deductible ($1,260): Age Area 1 Area 2 Under 65 $ $ Part B Deductible ($147): Rates effective January 2015 $ for all ages, all areas 44